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FOIA OFFICE USE: OR SANITATION PERMIT <br /> APPLICATION(Complete.........:... .......................................... <br /> in Triplicate) Permit No. <br /> .........................-----........................... <br /> This Permit Expires T Year From Date Issued Date Issued . °.:7.. <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 544 and existing Rules and Regulations: <br /> JOB ADDRESS/LOC.- ON .A'dl��_ ... . -:� 7 d° ................... ......CENSUS TRACT .......................... <br /> Owner's Name ... ". ..... .. .........•................................................................... . _: Phone .............. ............... <br /> Address y <br /> �............ Cit ......................•••............... <br /> Contractor's Name . ` ... --•.License #�t�- Phone <br /> y'I' '..... ........................ <br /> Installation will serve: Residence [] Apartment House C❑ Commercial ❑Trailer Court 0 <br /> Motel ❑ Other <br /> Number of living units------------- Number of bedrooms ......Garbage Grinder ............ Lot Size ...... .--........... <br /> Water Supply: Public System and name -----------------------------------_-.------------------...... ......... <br /> . _------•---Y-.._._....-•-•-. - Private [ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt 1:] Clay ❑ Peat Sand I ClayLoam <br /> Hardpan ❑ Adobe ❑ Fill Material .... If yes,type ........................... <br /> (Plot plan, showing size of lot, location ofsystem in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted ifublic sewer is available within 200 feet) <br /> PACKAGE TREATMENT [ SEPTIC TANK-tbf ..................... Liquid Depth .T......................� <br /> Capacity .1 -- Type . -1- ....... Material...+ !' ..... No. Compartments -U................1" <br /> Distance to nea est: Well ---- �.-�•/. .. .............Foundation Prop. Line ..�?� .-•--- <br /> LEACHING LINE [� No, of Lines ...... r............. Length of each line--------1��"���._.. Total Length ........ <br /> 0 <br /> ........ <br /> 'D' Box ... yp ....'Depth Filter Material ...� .�`..:._.... <br /> -- Type Filter Material ,�,� <br /> Distance to nearest: Weil ._..-IrE` __. _ Foundation _.._.�r ,��..... Property Line,1 ..........m <br /> SEEPAGE PIT (tilDepth _ -AfA—_- Diameter ...r 4�_ Number ..._..�............... Rock Filled Yes [�No 0 <br /> • Water Table Depth ----------I.e? ........................Rock Sze ...1 ....f!. ........-- <br /> Distance to nearest: Well ......... eZ ....Foundation .-- --. Prop. Line.. ... <br /> REPAIR ADDITION JPrev. Sanitation Permit 5 ............................................ Date ..) <br /> SepticTank (Specify Requirements) ...................................................................... ...........--......._..._....._..................................... <br /> Disposal Field (Specify Requirements) <br /> --------------------------------------._..------------------------------------•--...----•--- ..........----.......... .......................................................•............ i <br /> ----------- ---- ----- -----------------....._....---.......---.......-.--•---•-•-••--•-•-----•-•---•-......--••----------------- <br /> (Draw existing <br /> and required addition on reverse side) <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> f County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ............................... Owner <br /> �Z' ✓� Title -a ,�� .. <br /> (If other than owner) <br /> 5 <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _.. f --------------------------------------------------------- DATE .._.�Z3_.7__.l.-------- <br /> BUILDING PERMIT ISSUED ....._ DATE......................................... <br /> ........ <br /> ............ <br /> .... <br /> ................. <br /> . <br /> ADDITIONAL COMMENTS .... . <br /> -------------------------......... �G ---••-..._......------ f -•............-- ----..._.........••----•------------•-•---•--•-•-• ---- ---------------.......... <br /> ....................... :.......... ------•.......------.._-.............................................................-/. ............................... <br /> ............................................. :. ------ .... f` <br /> Final inspection by: ............. ..... <br /> -........................---................... ..........----••-- •------•----. ......Dote <br /> ;� ......... ..� ............ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> cc <br /> E. H.1.3 241-'68 Rev. 5M 7/723 ,14 <br />